Space Coast Healthcare And Rehabilitation Center

Based on observation, interview, and record review the facility failed to ensure the privacy, and confidentiality of resident records was maintained for 1 resident, of a total sample of 59 residents, (#519). Findings: On 1/16/25 at 10:20 AM, the computer on medication cart #1 located to the left of the nurses' station on the A Wing was noted with the screen open, facing the hallway. Pertinent information regarding resident #519 was visible to other staff, residents, and any visitors walking by the medication cart. On 1/16/25 at 10:24 AM, Registered Nurse (RN) F was standing at medication cart #1. She verbalized that she had previously locked her computer screen when she walked away from the medication cart. On 1/16/25 at 10:29 AM, the Assistant Director of Nursing (ADON) confirmed the computer screen on medication cart #1 was locked by RN F. The ADON stated she logged on to the computer at medication cart #1 to ascertain the correct spelling of resident #519's name and forgot to lock the screen when she walked away. She acknowledged that leaving the computer screen open was a Health…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to follow the grievance process to make a prompt effort to resolve the grievance and keep the resident apprised of the progress toward resolution for 1 of 5 residents reviewed for personal property, of a total sample of 59 residents, (#56). Findings: Review of resident #56's medical record revealed she was admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease, type 2 diabetes, and osteoarthritis. Review of the Minimum Data Set significant change in status assessment with Assessment Reference Date of 11/12/24 revealed resident #56 had a Brief Interview for Mental Status score of 15 out of 15 which indicated she was cognitively intact. On 1/13/25 at 1:42 PM, resident #56 shared she lost her cell phone in her previous room, a few weeks ago. She explained she reported it to staff, they searched for it, but it was not found, and the facility did not replace it. She indicated she had to buy a new phone. She recalled she had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide nail care and removal of chin hair for 3 of 3 residents observed for Activities of Daily Living (ADL) care of a total sample of 59 residents, (#13, #87, and #88). Findings: 1. Resident #13 was admitted to the facility on [DATE] with diagnoses to include dementia, stroke, history of traumatic brain injury, history of falls. The resident's Significant Change Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 11/23/24 revealed the resident's cognition was severely impaired. The assessment noted she was dependent on staff for all ADLs. The assessment noted the resident did not have any behaviors toward herself or others. On 1/13/25 at approximately 12:45 PM, the resident was eating lunch in the B wing dining room, and was seen picking up food with her hands. Her nails were long and had a dark substance under each nail. Resident #13 had an ADL care plan dated 10/03/24, which directed staff to, Check nail length…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide an on-going program of activities to meet the needs and preferences for 3 of 4 residents reviewed for activities, of a total sample of 59 residents, (#13, #40, and #88). Findings: 1. Resident #13 was admitted to the facility on [DATE] with diagnoses to include dementia, stroke, history of traumatic brain injury, history of falls. The resident's Significant Change Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 11/23/24 revealed the resident's cognition was severely impaired. The assessment noted she was dependent on staff for all Activities of Daily Living (ADLs). The assessment noted the resident did not have any behaviors toward themselves or others. Section F (Activities) indicated the following to be very important to the resident: music that she liked, going outside when the weather is good, activities that she enjoys with a group, reading magazines, newspapers and hearing the news. The resident's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure a resident received proper and timely treatment to maintain his vision for 1 of 3 residents reviewed for vision and hearing, of a total sample of 59 residents, (#32). Findings: Review of resident #32's medical record revealed he was readmitted to the facility on [DATE]. His diagnoses included type 2 diabetes, absence of right and left leg above the knee, and glaucoma. Review of the Minimum Data Set quarterly assessment with Assessment Reference Date of [DATE] revealed resident #32 had a Brief Interview for Mental Status score of 15 out of 15 which indicated he was cognitively intact. On [DATE] at 11:45 AM, resident #32 stated he was told by his optometrist he had bleeding behind his left eye and needed to see a specialist. He explained she wrote it on her visit note last year but the facility did not follow up timely. He indicated when he finally saw the specialist, a treatment of injections was started but he was told the bleeding might not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure an intravenous (IV) dressing was changed as ordered for 1 of 2 residents reviewed for IV therapy, of a total sample of 59 residents, (#513). Findings: Resident #513 was admitted to the facility on [DATE] with diagnoses including encounter for surgical aftercare following surgery on the skin and subcutaneous tissue, other staphylococcus as the cause of diseases classified elsewhere, local infection of the skin and subcutaneous tissue, personal history of methicillin resistant staphylococcus aureus (MRSA) infection. MRSA is a type of bacteria that is resistant to several antibiotics. The risk is increased for people in nursing homes or exposure to crowded, unhygienic places. If left untreated MRSA infections can cause sepsis or death, (retrieved from cdc.gov/mrsa on 2/03/25). Review of the Minimum Data Set admission assessment with assessment reference date of 1/01/25 revealed resident #513 had a Brief Interview for Mental Status…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to implement pharmacy recommendations and physician orders and failed to document a physician rationale for not following pharmacy recommendations for 3 of 5 residents reviewed for Medication Regimen Review (MRR), of a total sample of 59 residents, (#61, #11, and #34). Findings: 1. Resident #61 was admitted to the facility on [DATE] with diagnoses to include dementia, breast cancer, anxiety, delusional disorders, anemia, hypertension, and pain. The Order Summary Report revealed the resident had active medication orders included, Remeron 15 milligrams (mg) for insomnia, Lorazepam 0.5 mg daily for agitation, Norco 5/325 mg for pain, Pantoprazole 40 mg for acid reflux, Risperdal 0.25mg for adjustment disorder, Senna tab 8.6 mg for constipation, Singular 10 mg for asthma, Zoloft 50 mg for depression, and Melatonin 5 mg at bedtime for insomnia. Review of the Medication Regimen Review (MRR) recommendations for resident #61 included: In July 2023 resident #61…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to ensure an as needed (PRN) order for a psychotropic drug was limited to fourteen (14) days for 1 of a total sample of 59 residents reviewed, (#30). Findings: Resident #30, a [AGE] year-old male was initially admitted to the facility on [DATE], with his most recent readmission on [DATE]. His diagnoses included schizophrenia, psychosis, dementia, depression, seizures, and chronic kidney disease. Review of the medical record revealed a physician order dated 10/01/24 for Xanax 1 milligram (mg) every 12 hours as needed for agitation. The order did not have a stop date. Xanax is used to treat anxiety disorders and anxiety caused by depression, (retrieved on 2/03/25 from www.drugs.com). On 1/16/25 at 9:05 AM, the A Wing Registered Nurse/Unit Manager (RN/UM) stated PRN Xanax was normally prescribed for 14 days. She stated that if the medication was used occasionally, it could be continued for 30 days, and if not used the medication should be discontinued. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to prevent a mentally impaired resident from exiting the facility unsupervised and failed to provide adequate supervision and a secure environment for 1 of 4 residents reviewed for elopement, out of a total sample of 12 residents, (#2). Findings: Review of the medical record revealed resident #2 was readmitted to the facility on [DATE] with diagnoses including osteomyelitis (infection in the bone caused by bacteria or fungi) of the right ankle and right foot, type 2 diabetes with foot ulcer, cognitive communication deficit, difficulty walking, delusional disorders, schizoaffective disorder, and anxiety. Review of the annual Minimum Data Set (MDS) assessment with Assessment Reference Date of 2/26/24 revealed resident #2's Brief Interview for Mental Status score of 6 out of 15, which indicated severe cognitive impairment. The MDS assessment showed resident #2 sometimes felt lonely or isolated from those around him. The assessment revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to report suspected staff abuse of a resident to the state licensing authority for 1 of 4 residents reviewed for Abuse, of a total sample of 12 residents, (#5). Findings: Review of the medical record revealed resident #5, a vulnerable [AGE] year old male was admitted to the facility from an acute care hospital on 1/23/23 with diagnoses of spinal stenosis (narrowing), failure to thrive, malnutrition, impaired cognitive functioning and awareness symptoms, peripheral vascular disease (impaired circulation in the limbs), Chronic Obstructive Pulmonary (Lung) Disease, right foot drop, and contractures (muscle/tendon shortening/rigidity). The Minimum Data Set Quarterly Assessment with Assessment Reference Date 10/26/23 noted resident #5 scored 9 out of 15 on the Brief Interview for Mental Status that indicated he was moderately cognitively impaired. The assessment showed the resident had no indicators of psychosis, and he had not rejected evaluation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure scheduled medications were administered as ordered and according to professional standards of practice for 17 of 18 residents reviewed for medication administration out of a total sample of 19 residents, (#1, 4, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 & 19). Findings: On 2/12/24 at 11:09 AM, Registered Nurse (RN) A was observed at her medication cart on the A wing. She explained she had just finished administering morning medications. She acknowledged the morning medications were administered late. On 2/12/24 at 11:03 AM, Licensed Practical Nurse (LPN) B stated the usual nurse staffing for day shift at the facility was four nurses, two on each wing. LPN B explained that occasionally, like yesterday they were staffed with only 3 nurses so one nurse had a split assignment between the two units. She noted that when this occurred, medications were often given late, as they did not receive help from Administrative staff such as the Director of Nursing (DON), the Unit Managers (UM) or the Minimum Data Set…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident's environment was free from accident hazards and each resident received adequate supervision to prevent accidents for 4 of 4 residents reviewed for smoking out of a total sample of 42 residents, (#17, #29, #42, and #74). Findings: 1. Review of resident #17's medical record revealed he was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, mild cognitive impairment, and glaucoma. Review of the quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 2/22/23 revealed resident #17's Brief Interview for Mental Status (BIMS) score was 10 out of 15, which indicated moderate cognitive impairment. He required supervision for bed mobility, transfers, locomotion, dressing, toilet use and personal hygiene. The annual MDS assessment with ARD of 8/24/22 noted resident #17 used tobacco. Review of a care plan dated 4/16/20 revealed resident #17 was to be supervised…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, and interview, the facility failed to store food safely to prevent foodborne illness for residents residing in the facility. Finding: On 5/15/23 at 10:05 AM, the initial kitchen inspection was conducted with the Certified Dietary Manager (CDM). The walk in refrigerator contained food items that were either previously opened or cooked that were not labeled to identify the food item and or the open/discard date. In the walk-in refrigerator there was a box on the bottom shelf that had sausage links in a hermetically sealed plastic bag that had been opened with no open/discard date. There was also a bag of chicken in a metal pan that was thawing and it did not have a label to indicate when the chicken was placed in the refrigerator for thawing, the intended date of use or discard date. There was a dinner plate with an egg sandwich covered with plastic wrap. There was no indication as to when the sandwich had been made or a discard date. There was also a small bowl of mandarin oranges, a small container filled with what looked like gelatin, two containers with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, and interview, the facility failed to maintain the area surrounding the dumpster in a clean and sanitary manner. Findings: On 5/15/23 at approximately 10:05 AM, the dumpster area was observed with the Certified Dietary Manager (CDM). There were two dumpsters with doors closed but refuse and debris were noted on the ground around the dumpsters. There were clear plastic cups, Styrofoam cups, cup lids, surgical face mask and disposable gloves on the ground. The CDM stated he usually checked every morning to ensure the area around the dumpsters was clean. He acknowledged the facility staff needed to ensure the dumpsters and the proximal area were maintained in a sanitary manner to prevent the harborage and feeding of pests.

Based on observation, and interview, the facility's Governing Body failed to implement policies regarding the management and operation of the facility to ensure the building's hot water was maintained to ensure residents comfort for bathing and hygiene in 32 resident bathrooms on 1 of 2 units, (Unit B). During a complaint, and recertification and relicensure survey that began on 5/15/2023, it was identified that 32 resident room bathrooms on 1 of 2 units were not supplied with hot water. Facility staff stated the problem started in late January 2023 due to plumbing damage that caused an outage to the entire B unit. The facility's governing body approved funding that allowed the facility to partially complete repairs in March 2023 which provided hot water to the Unit B shower room only. Findings: On 5/15/2023 between 10:56 AM and 2:09 PM, it was identified there was no hot water in any resident room bathrooms on Unit B of the facility. On 5/18/2023 at 1:35 PM, the facility's Administrator explained the former Maintenance Director reported to him that per the Regional Plant Operations…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to maintain the walk-in refrigerator in a safe and clean operating condition. Findings: On 5/15/23 at 10:15 AM an observation of the walk-in refrigerator (milk cooler) revealed a 48 inch x 1 inch separation along in the entire width of the metal floor in the center of the refrigerator. Various areas of the floor separation had water seeping through the gaps. Along the separation were gaping holes measuring 6 inches x 7 inches, 3 inches x 1/12 inches, and 1/1/2 inch x 2 inches. Two gaps in the metal floor had adjoining areas with a 3/8 inch rise on the floor. A water stain measuring 48 1/4 inches long x 2 inches wide was noted along the north side of the walk-in refrigerator. The Certified Dietary Manager (CDM) acknowledged the holes in the floor and the water seepage into the holes. Review of work orders dated 12/28/22, 3/31/23, and 4/20/23 were submitted with high priority for a floor in milk cooler but the repairs had not been done.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow the grievance process related to missing personal items for 1 of 3 residents reviewed for personal property in a total sample of 42 residents, (#35). Findings: Review of resident #35's medical record revealed he was readmitted to the facility on [DATE] with diagnoses including bilateral above the knee amputation and type 2 diabetes. Review of the quarterly MDS assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15 which indicated intact cognition. On 5/17/23 11:41 AM, resident #35 stated he was missing two shirts he purchased a few months ago, and the facility did not want to refund him because he had no receipt. He explained he had charged his credit card for this purchase, but he was unable to obtain a copy of the statement as he did not recall the exact date of the purchase and there was a fee to get the copies. He shared he had mentioned it to the staff and requested to see the Social Services Director (SSD) but she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Review of the medical record revealed resident #17 was admitted to the facility on [DATE] from an inpatient psychiatric hospital with schizoaffective disorder, bipolar type, other schizophrenia, and mild cognitive impairment. The Minimum Data Set quarterly assessment with Assessment Reference Date 2/22/2023 showed the resident scored 10 out of 15 on the Brief Interview for Mental Status, which indicated the resident was cognitively impaired. The assessment noted the resident had received antipsychotic medications for 7 out of 7 days during the look back period. The comprehensive care plan included focuses for potential ADL self-performance deficits related to schizophrenia and anxiety, refusals of medications, mild cognitive impairment, and monitoring for adverse effects of antipsychotic medication use. The Order Summary Report noted active medication orders for Zyprexa 15 milligrams (MG) once daily at bedtime for delusions and paranoia, and Divalproex Sodium 500 MG twice daily for hallucinations and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to refer 1 resident for a level 2 Preadmission Screening and Resident Review (PASARR), (#4), and failed to submit a level 1 PASARR in accordance with the state process for 1 resident, (#77) out of 4 residents reviewed for PASARR from a total sample of 42 residents. Findings: 1. Review of the medical record revealed resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] from an acute care hospital with diagnoses including schizophrenia, depression, anxiety, affective mood disorder, and stroke. The Minimum Data Set quarterly assessment with Assessment Reference Date 3/21/2023 showed the resident was unable to complete the Brief Interview for Mental Status and noted he was severely cognitively impaired. The assessment noted the resident was dependent on staff to complete Activities of Daily Living (ADL), and received opioid medication for 3 out of 7 days during the look back period. The comprehensive care plan included focus for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide intravenous (IV) care and services according to standards of practice and plan of care for 1 of 1 resident reviewed for IV care out of 42 total sampled residents, (#68). Findings: Resident #68's medical record revealed she was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include femur fracture, dementia, and cystitis. Review of the Minimum Data Set (MDS) Modification of admission assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 05 out of 15 which indicated resident #68 had severe cognitive impairment. Review of the medical record for resident #68 revealed physician orders dated 4/17/23 that read, Insert Peripherally Inserted Central Catheter (PICC) for long term IV antibiotic administration. PICC line is a long, thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart . A PICC line gives your doctor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that a resident was assessed to be safe and clinically appropriate to self-administer an Albuterol inhaler for 1 of 1 resident reviewed for self-admisnitration (#192). Findings: Resident #192 was admitted to the facility on [DATE] from the hospital with diagnoses of Chronic Obstructive Pulmonary Disease (COPD) with Acute Exacerbation, Hypertension, and Shortness of Breath. Chronic Obstructive Pulmonary Disease with acute exacerbation is a long-term lung condition that makes it hard for you to breathe with flare ups of more trouble breathing. (retrieved on 6/17/21 from www.webmd.com). Review of the Admission/readmission Data Collection-CHC form, dated 6/10/21, revealed resident #192 was alert, oriented to person, place and time, made herself understood and had the ability to understand others. Review of physician orders showed a medication order, dated 6/10/21, for Albuterol Sulfate HFA Aerosol Solution 1 puff by oral inhalation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to provide housekeeping services necessary to maintain a sanitary, orderly, and comfortable interior in 1 of 32 rooms on 1 of 2 units (B-Wing, B23). Findings: On 6/15/21 at 9:08 AM, the privacy curtain in room B23 was soiled with stains. The curtain had more than 10 dried stains from light to dark brown. The stains covered an area of about 3 feet (ft.) by 3 ft. and were a penny to a quarter in size. On 6/16/21 at 12:32 PM, observation of room B23's privacy curtain was conducted with the Housekeeping Manager. He acknowledged the brown colored stains and stated the curtain needed to be changed right away. He stated the housekeeper was responsible to check the curtains every day when cleaning the room, and if dirty, remove and replace it with a clean one. He stated he performed weekly random rooms audits that included inspecting the curtains. Review of the Cubical Curtain Audit form for June 2021 revealed that room B23's privacy curtain was inspected, identified as dirty, removed and replaced on 6/07/21. On 6/17/21…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow the grievance process related to missing personal items for 2 of 2 residents reviewed for personal property in a total sample of 52 residents (#26 & #49). Findings: 1. Resident #26 was admitted to the facility on [DATE] with diagnoses that included aphasia, bilateral deafness, and dementia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 3/22/21, revealed the Brief Interview for Mental Status (BIMS) screening was not conducted because the resident was rarely or never understood. The MDS assessment indicated he had memory problems and his cognitive skills were severely impaired. Resident #26's medical record showed his sister was his responsible party. On 6/15/21 at 2:01 PM, during a telephone interview, resident #26's sister stated on her brother's admission to the facility in September 2020, she brought him new items including socks, bedroom slippers, pajamas, t-shirts, and shoes. She explained she was not able to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the Ombudsman of a transfer to the hospital for 1 of 2 residents reviewed for hospitalization, of a total sample of 52 residents (#36). Findings: Resident #36 was admitted to the facility on [DATE] with diagnoses including cerebral infarction, and end stage kidney disease requiring renal dialysis. A progress note dated 11/10/20 read, Resident sent to hospital, sitting in wheelchair waiting to go to dialysis. He was unable to hold self up in wheelchair would look at staff and not speak. Physician ordered to send to ER. Resident #36 was unable to recall why he was sent to the hospital and stated the reason would be in his record. Review of the medical record revealed the resident was hospitalized on 10/29 to10/30/20, 11/10 to17/20, and 11/25 to 12/04/20. On 6/17/21 at 3:00 PM, the Director of Social Services (DSS) stated the resident went to the hospital before she began working at the facility and she was unable to retrieve the former DSS's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to initiate baseline care plans and/or provide copies of baseline care plans to 4 of 4 residents or their representatives, of a total sample of 52 residents (#32, 43, 72 & 82). Findings: 1. Resident #32's medical record reflected the resident was admitted to the facility on [DATE] with diagnoses including paraplegia (paralysis of the legs and lower body), depression, and chronic pain syndrome. The medical record did not contain a baseline care plan. On 6/17/21 at 3:41 PM, the A Wing Unit Manager (UM) stated the admitting nurse should complete the baseline care plan and review it with the resident or the resident's representative. She explained the resident or the representative should receive a copy of the baseline care plan at that time. The A Wing UM searched through resident #32's chart and was unable to find a baseline care plan. On 6/17/21 at 4:00 PM, resident #32 stated he was unable to recall if anyone ever discussed a care plan with him. 2.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide appropriate care and treatment to promote healing of a left heel pressure ulcer for 1 of 1 resident reviewed for pressure ulcers in a total sample of 52 residents (#23). Findings: Resident #23 was admitted to the facility on [DATE] with diagnoses including muscle weakness, coronary artery disease, peripheral vascular disease, and dementia. A diagnosis of stage 3 pressure ulcer (PU) of the left heel was added on 2/26/21. A stage 3 PU is a Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.